1. Wellness Issues for Emergency Medicine Residents Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

2. Wellness Issues for E.M. Residents Lecture Outline  General importance of wellness considerations  Work scheduling  Family interactions  Outside activities  Personal health  Support mechanisms

3. Wellness Issues for E.M. Residents Lecture Goals  Familiarize E.M. residents with wellness issues  Help individuals develop personal wellness plans and programs  Promote discussion of wellness issues

4. What is "wellness" ?  Same as "well-being"  Person's state of being should be : ƒ Pleasing ƒ Desirable ƒ Appropriate ƒ Healthy  Cannot be taken for granted but must be planned  Goal is to enable successful & comfortable coping with stresses

5. Stress Factors in E.M. Residency  Intense work environment  Patient demands & expectations  Risk of illness / injury  Long work hours  Limited time for family / recreation  Sleep deprivation  Criticism by other specialties  Perception of lack of knowledge or confidence

6. Stress Factors on Residents from the E.D. Work Environment  Time pressure to see patients quickly  Large numbers of patients  Must manage multiple simultaneous patients  Other concurrent work duties & demands ƒ Answering referral phone calls ƒ Answering paramedic radio calls ƒ Informing relatives & other physicians  Unpredictability of patient presentations

7. Types of Patients that Cause Stress for E.M. Residents  Severely injured, especially children ƒ Disfigurement  Malodorous  Victims of deliberate harm  Hostile  Combative  Inappropriately demanding  Psychiatric

8. Coping with the Stress of Caring for the Severely Injured  Focus on providing care for the patient  Involve other E.D. personnel as a team  Treat the patient's pain early  Try to see a mix of acute and minor cases (don't just see a continuous stream of severe cases only)

9. Coping with the Hostile Patient  Try to find out the real reason for their hostility ƒ Often is due to fear or anxiety which can be addressed  Explain situation carefully & completely  Involve the attending early  If situation seems unsalvagable, then transfer care of patient to another resident

10. Coping with the Inappropriately Demanding Patient or Family  First : carefully explain the situation  Second : find out what is really concerning the patient & address that  Third : have the attending speak to the patient  Fourth : have a nurse or other non-physician re-explain things to the patient  Finally : don't allow yourself to do something inappropriate just to satisfy the patient or family

11. Coping with the Stress of Seeing Psychotic Psychiatric Patients  See them only in a secure area or accompanied by other E.D. staff  Utilize sedative medication early after medical clearance  Have a plan in place for early involvement of psychiatrist and admission or transfer  Don't spend fruitless time trying to reason with the acutely psychotic patient

12. Coping Measures for General E.D. Workload Stress  Take a couple of short breaks out of sight of the patients  Don't skip meals  Enlist appropriate help of co-workers ƒ Obtain extra personnel if needed ƒ Call personnel in earlier

13. Measures for Dealing with the Stress of Patients Dying in the E.D.  Residents should have training in "death- telling" from faculty  Should involve counselor, chaplain, or nurse to assist in talking to family  May help to have conference afterward of all involved personnel to review case  Residents should have access to counselors themselves if needed  Should quickly focus on caring for the next patient

14. Coping with the Stress of Shift Work  E.M. physicians spend more time at night at work than most other physicians ƒ But have less on-call time and fewer unexpected work time demands  Should only have limited responsibilities for work or conferences on day following night duty  Should have at least 24 hours off after night shift before switching to day shift  Should ensure equitable distribution of night shifts among residents & faculty  Should allow night residents to sleep if not busy

15. Home Aspects of Coping with Night Shift Work  Don't drink too much coffee in the morning if planning to sleep  Have "breakfast" before going to bed  Try to ensure quiet sleeping area (turn phone off)  Make sleeping area as dark as possible (blackout curtains)  Sleep till afternoon if in a series of night shifts  Set alarm & wake by noon if finishing a single or series of night shifts to allow return to normal sleep schedule at night

16. Improving Relations with Co- workers in the E.D.  Should have regular meetings where all personnel are invited to discuss problems  Critical Incident Stress Debriefing may be useful for groups involved in major incident  Helpful to have social events outside the hospital for staff several times per year  Interactive problems should initially be addressed in private

17. Improving Relations with Your Family or Significant Others  Most Important Principle : DON'T NEGLECT YOUR FAMILY !  Must allocate sufficient dedicated time to family  Have family tour the E.D. so they know some of the work stresses you face  Resident families should get to know each other, communicate regularly, and agree to help each other out regularly

18. Methods for Residents' Families or Significant Others to Interact Supportively  Set up rotating baby-sitting service  Rotating evening "pot-luck" dinners  Regular group meetings for support  Attend hospital or department social functions

19. Importance of Personal Health and Well-Being  Maintaining one's personal health ensures greater enjoyment & efficiency at work  Maintain balanced diet ƒ Consider bringing food pre-prepared at home when on work duty ƒ Try to stick to regular meal schedule  Regular exercise  Avoid drugs, tobacco, & excessive alcohol  Sufficient sleep  Extra rest or limit activity if infectious illness occurs

20. Key Method to Help Ensure Wellness : Make a Personal Schedule  VERY IMPORTANT to write out a general long term schedule & a more detailed short term (one month) schedule  THEN STICK TO THE SCHEDULE !  Important to plan time for : ƒ Family ƒ Exercise ƒ Recreation / hobbies ƒ Social events ƒ Vacation ƒ Academic pursuits

21. Recommended Considerations for Your Personal Schedule  Consult your family or significant other for events significant for them  Be flexible with your fellow residents to cover work duty to allow them to attend their important events so they will do the same for you  Schedule specific times for exercise

22. Importance of Developing Hobbies  Don't center your life around medicine only  Should develop interests outside medicine  I recommend pursuing at least one "indoor" and one "outdoor" hobby ƒ So if the weather happens to be bad on one's day off, the indoor hobby can be enjoyed  Best hobby choices are ones that can be shared by spouse, significant other, or family members  Hobbies that create something can be the most rewarding

23. Indoor Hobbies to Consider  Painting / drawing / drafting  Music  Sewing  Indoor gardening  Woodworking  Model building  Toy making  Other crafts  Board games / computer games  Film developing  Cooking  Wine or beer making Note that watching TV or reading do not count as hobbies

24. Outdoor Hobbies to Consider  Sports  Gardening / landscaping  Photography  Hiking  Camping  Swimming  Outdoor toy building  Bicycling  Boating / canoeing  Target shooting / hunting  Archery  Paint ball

25. Other Activities to Consider Outside the Hospital  Must be careful with these to not interfere with time for family ƒ Youth counseling ƒ Sports team supervision ƒ Lecturing to students or the public ƒ Career advising for students ƒ Volunteer work with elders ƒ Political activism

26. Importance of Career Planning  Should establish & prioritize career goals  Make sure family or significant other has input into & understands your career goals  Must integrate financial planning  Discuss with E.M. faculty  Set realistic goals  Update or change as needed

27. Establish a Personal Support System  Prearrange a "confidante" person to whom you can talk about any problem ƒ A person who understands stresses of medical career is best, but does not necessarily have to be a person in the medical field  E.M. faculty should arrange availability of other counselors as needed  Make sure confidentiality is assured

28. Helping Your Fellow E.M. Residents  Should have regular meetings of all the residents to discuss problems  Should maintain cooperative, rather than competitive, atmosphere in the residency  If a resident shows signs of stress or work decompensation, other residents should encourage counseling and be extra supportive  All residents should maintain willingness to make schedule changes and cover for times of illness for other residents

29. Options to Deal With Major Unresolved Stresses  Discuss carefully with counselor first  Take a vacation  Switch rotations with another resident  E.M. Program Director may grant a temporary reduced work schedule  Take on a new "distracting" project such as an academic project

30. Wellness Issues for E.M. Residents Summary  Stick to a prearranged personal schedule  Maintain healthy lifestyle  Devote sufficient time to family  Set career goals  Maintain flexibility & helpfulness for other residents  Utilize personal support structure early for any major problems